Provider Demographics
NPI:1144250549
Name:LARSON, DANA (MS)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 S UTICA AVE
Mailing Address - Street 2:STE E
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-6520
Mailing Address - Country:US
Mailing Address - Phone:918-744-3528
Mailing Address - Fax:918-744-3529
Practice Address - Street 1:1923 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-6520
Practice Address - Country:US
Practice Address - Phone:918-744-3528
Practice Address - Fax:918-744-3529
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16757207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100210820AMedicaid
OKS011401028Medicare ID - Type Unspecified
OK100210820AMedicaid